Treatment of recurrent sinonasal polyposis with steroid-infused carboxymethylcellulose foam

Correlation of polyp grading scales with patient symptom scores and olfaction in chronic rhinosinusitis: a systematic review and meta-analysis

BACKGROUND

Various nasal polyp (NP) scoring systems have been proposed and used in the literature. However, no single system has been identified as superior. Correlations between NP scoring systems and patient symptoms, quality of life (QOL) or olfaction vary widely.

METHODS

A systematic search of PubMed, CINAHL, Scopus, and Cochrane Library was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline. Any study examining endoscopy scores and symptom, QOL or olfaction measures in cross sectional manner or after therapeutic intervention were included.

RESULTS

This review identified 55 studies for a pooled meta-analysis of Lund-Kennedy (LK-NP) polyp scores (N = 6), Meltzer scores (N = 6), Nasal polyp scores (NPS; N = 19), Total polyp score (TPS; N=8) Lilholdt scores (N = 8), Olfactory cleft endoscopy score (OCES; N =4), Discharge, inflammation, polyp/edema score (DIP; N = 2), and Perioperative sinus endoscopy score (POSE; N = 2). Meta-regression assessed correlations between NP grading systems and SNOT-22, nasal congestion scores, total nasal symptom scores (TNSS), and Smell Identification Test-40 (SIT40). None of the NP grading systems correlated significantly with any symptom, QOL or olfactory metric. In intervention studies of surgery or monoclonal antibody treatment, changes in NPS scores did not correlate with any patient reported outcome measure (PROM) or olfactory outcomes.

CONCLUSION

Current NP endoscopic scoring systems are not associated with PROMs such as SNOT-22, nasal congestion scores, and TNSS as well as objective measures of olfaction. NP grading systems with improved clinical utility are needed.

In-Office Corticosteroid Placement in the Management of Chronic Rhinosinusitis

OBJECTIVES

Corticosteroids represent one of the mainstays of medical management of chronic rhinosinusitis (CRS) in both locally acting topical and systemic derivations. The application of topical corticosteroids is limited by a variety of factors including patient compliance, positioning, and nasal anatomy. Systemic corticosteroids confer a risk of medical complication that restricts their ability to be used repeatedly. The objective of this publication is to review the evolution of the in-office intranasal placement of corticosteroids in the management of CRS. The efficacy, outcomes, and safety of a variety of corticosteroid-containing devices meant to be placed in an office setting are reviewed.

METHODS

Pertinent literature was reviewed and summarized beginning with the earliest reports of direct intralesional injection of corticosteroids up through manufactured modern-day bioresorbable implants that contain corticosteroids.

RESULTS

The utilization of in-office placement of corticosteroid-containing material and implants has rapidly evolved since the concept was introduced, particularly in the last decade. Modern-day corticosteroid-eluting implants are reliably placed in the office, yield results across a range of objective and subjective outcomes, may decrease the need for revision endoscopic sinus surgery, and have a favorable safety profile.

CONCLUSIONS

In-office placement of corticosteroid-containing stents are a viable treatment option for select patients, particularly those wishing to avoid revision surgery, and should be considered an important adjunct for treatment of refractory CRS in an otolaryngologist's armamentarium.

The Effect of Triamcinolone-Soaked Gelfoam in Patients with Polypoid Mucosal Change after Endoscopic Sinus Surgery

Background and Objectives: Chronic rhinosinusitis with nasal polyps (CRSwNP) recurs frequently after endoscopic sinus surgery (ESS). The aim of study was to evaluate the efficacy of triamcinolone-soaked absorbable gelatin foam (gelfoam) as a treatment for recurred polypoid changes after ESS.Subjects and Method: A total of 35 patients and 57 nasal cavities was retrospectively reviewed. All patients underwent triamcinolone- infused gelfoam packing for 1 week under nasal endoscopic guidance. Endoscopic scores were evaluated at 1 week, 1 month, and 3 months. We analyzed clinical characteristics between success and failure groups.Results: Endoscopic scores were significantly improved after triamcinolone-soaked gelfoam packing, and the effects were maintained at 3-month follow-up (1.85±0.61 vs. 0.82±0.77, p＜0.001). Duration between surgery and gelfoam packing was shorter in the success group compared to the failure group (8.2±6.9 vs. 13.7±8.4 weeks, p=0.033). Serum eosinophil cationic protein and tissue eosinophil counts were significantly higher in the failure group (p=0.025 and p=0.010, respectively).Conclusion: Triamcinolone-soaked gelfoam packing is an effective and safe method for managing recurrent polypoid change in patients with CRSwNP after ESS. Early intervention contributed to a successful result, and eosinophilic inflammation was associated with poor outcomes.

Current trends in topical therapies for chronic rhinosinusitis: update and literature review

INTRODUCTION

Chronic rhinosinusitis (CRS) affects millions of patients worldwide. The disease is multifactorial with influences including anatomic factors, immunological disturbances, and altered sinonasal microbiome. Although oral medications are effective in controlling some symptoms, they are associated with side effects and long-term use is not ideal. Thus, topical therapies have emerged as an alternative delivery method for localized, high-concentration medication with less side effects. Areas covered: This is a review of the various topical therapies available or under investigation for the management of CRS. Common medications such as saline, steroids, and antimicrobials will be discussed. Furthermore, additives including manuka honey, xylitol, surfactant, N-chlorotaurine, Dead Sea salt, and sodium hyaluronate will be addressed. Innovations in topical therapies, such as drug-eluting biomaterials and photodynamic therapy, will also be reviewed. Expert opinion: Although topical therapies provide a high dose of active substance at the site of disease, their efficacy in CRS is not clear. Topical saline and intranasal steroids appear to consistently demonstrate therapeutic benefits. However, other topical medications require further investigation to determine long-term clinical efficacy and safety. A better understanding of their effects on the sinonasal mucociliary system is needed before they become the standard of care in CRS.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

Product comparison model in otolaryngology: Equivalency analysis of absorbable hemostatic agents after endoscopic sinus surgery

OBJECTIVES/HYPOTHESIS

Evidence-based medicine in otolaryngology literature continues to be lacking, especially with regard to new products brought to market. The marketing of products often includes statements of benefit that have limited objective support in research or literature. To address this, and to adequately determine product equivalency/superiority, careful evaluation must be made. In order to establish standards for this process in rhinology products, we directly compare three different absorbable hemostatic agents in patients with chronic rhinosinusitis (CRS) after undergoing endoscopic sinus surgery (ESS), using both objective and subjective outcomes.

STUDY DESIGN

Double-blinded prospective (level 1) comparison and equivalency analysis of three plant-based absorbable hemostatic agents (carboxymethylcellulose [CMC] gel, mucopolysaccharide hemospheres (MPH), and potato starch wafer) in patients undergoing bilateral ESS.

METHODS

Patients with medically refractory CRS who underwent bilateral ESS were recruited and prospectively followed. At the conclusion of ESS, one of three different hemostatic agents was applied to each nasal passage. Subjective patient data was obtained using rated symptoms compared between the two sides (nasal obstruction, bleeding, pain, and nasal discharge) at baseline and on postoperative days 1, 7, and 14. Objective data was obtained by blinded endoscopic scoring to rate mucosal edema, inflammation, granulation, crusting, infection, and synechiae formation on postoperative weeks 1, 3, and 6.

RESULTS

Forty-eight patients who underwent ESS for CRS were included. There is no statistical difference in subjective scores for any of the variables measured, although (MPH) nearly reached statistical significance at postoperative day 7 for increased pain (P = 0.06) and obstruction (P = 0.22). Objective measures showed equivalency between all products, except the CMC gel approached significance at week 3 for increased crusting (P = 0.10), granulation (P = 0.24), and debridement (P = 0.07). At 6 weeks, increased debridement (P = 0.14) also approached significance.

CONCLUSION

Careful and deliberate consideration should be taken when choosing products to assist our surgical endeavors. Subjectively, patients treated with MPH showed near-significant increases in pain and obstruction. In objective measures, CMC gel nearly reaches significance for more postoperative debridement, with increased crusting and inflammation. Product choice could consider these factors, although it remains at the discretion of the surgeon. This model of comparison allows careful product comparison and should be applied to other hemostatics, as well as other materials in use in otolaryngology.

LEVEL OF EVIDENCE

1b. Laryngoscope, 126:S5-S13, 2016.

Systemic effects and safety of triamcinolone-impregnated nasal packing after endoscopic sinus surgery: a randomized, double-blinded, placebo-controlled study

BACKGROUND

Steroid-infused absorbable nasal dressings after endoscopic sinus surgery (ESS) have been used to improve wound healing and to reduce the recurrence of polyps. However, their systemic effects are not well known. The purpose of this study was to evaluate the systemic effects and safety of steroid-impregnated absorbable nasal packing after ESS.

METHODS

Patients who underwent bilateral ESS for chronic rhinosinusitis were recruited and randomized into two groups. Ten patients in the triamcinolone (TA) group received a TA (20 mg)-soaked bioabsorbable dressing in both nasal cavities while 10 patients in the control group took saline-impregnated dressing in both nasal cavities. Nasal dressings were not removed until postoperative day 10. Serum cortisol, 12-hour urine cortisol, serum adrenal-corticotropic hormone (ACTH), and serum osteocalcin were measured preoperatively and on postoperative days 2 and 10. Serum cortisol levels were checked 1 day after surgery additionally, while urine cortisol levels were not checked at postoperative day 10.

RESULTS

All 20 patients completed this study. The serum cortisol levels were significantly suppressed at postoperative days 1 and 2 in the TA group. Serum ACTH and 12-hour urine cortisol levels were lower 2 days after surgery in the TA group, although these changes were not statistically significant. There were no differences in all other parameters between the TA and control groups on postoperative day 10.

CONCLUSIONS

TA-impregnated nasal dressings suppress serum cortisol levels during the early postoperative period. This systemic effect was recovered gradually and normalized 10 days after the operation.

Topical triamcinolone acetonide/carboxymethylcellulose foam for acute exacerbations of chronic rhinosinusitis/nasal polyposis

BACKGROUND

Chronic rhinosinusitis with nasal polyposis (CRS/NP) is a medical disease that is managed more effectively after endoscopic sinus surgery (ESS). Despite topical treatment with intranasal steroids, acute inflammatory exacerbations (AEs) are common and are typically treated with oral prednisone, which has significant and well-documented side effects. The objective of the current study was to critically evaluate the topical application of triamcinolone acetonide (80) in carboxymethylcellulose (TA/CMC) foam for AEs in CRS/NP patients after ESS.

METHODS

CRS/NP patients managed with ESS by a single rhinologist over a 5-year period were included in the study. Data were reviewed regarding demographics, number of AEs, revision surgery, 22-item Sino-Nasal Outcomes Test (SNOT-22) scores, frequency of oral prednisone and/or TA/CMC, and notable side effects.

RESULTS

A total of 371 CRS/NP patients were treated with ESS over a 5-year period. Mean follow-up was 49.3 weeks (range, 2-249 weeks). During this time period, 130 patients (46 years; range, 28-48 years) developed a cumulative 267 AEs. Before initiating use of TA/CMC in 2010, 66 AEs were treated with prednisone. Subsequently, 116 of 201 AEs were managed with TA/CMC with a sequential decrease in prednisone use over the last 3 years (77, 39, and 32%). SNOT-22 scores (n = 33) decreased significantly after TA/CMC instillation (preinstillation, 1.69 ± 0.86, versus postinstillation, 1.23 ± 0.8; p < 0.01).

CONCLUSION

Management of AEs with TA/CMC decreased overall prednisone use in a large population of CRS/NP patients in this retrospective evaluation. TA/CMC appears well tolerated and is a useful treatment option for AEs in postoperative CRS/NP patients.

Sinus surgery and delivery method influence the effectiveness of topical corticosteroids for chronic rhinosinusitis: systematic review and meta-analysis

BACKGROUND

Published randomized controlled trials (RCTs) on the efficacy of intranasal corticosteroid (INCS) in chronic rhinosinusitis (CRS) use either nasal delivery (nasal drop or nasal spray) or sinus delivery (sinus catheter or sinus irrigation) in patients with or without sinus surgery. This influences topical drug delivery and distribution. The effect of these factors on the published results of RCTs is assessed. This systematic review explores the strength of evidence supporting the influence of sinus surgery and delivery methods on the effectiveness of topical steroids in studies for CRS with meta-analyses.

METHODS

A systematic review was conducted of RCTs comparing INCS with either placebo or no intervention for treating CRS. Data were extracted for meta-analysis and subgroup analyses by sinus surgery status and topical delivery methods.

RESULTS

Forty-eight studies (3961 patients) met the inclusion criteria. INCS improved overall symptoms (standardized mean difference [SMD], -0.49; p < 0.00001) and the proportion of responders (risk ratio [RR], 0.59; p < 0.00001) compared with placebo. It decreased nasal polyp size with a greater proportion of responders (RR, 0.48; p < 0.00001) and prevented polyp recurrence (RR, 0.59; p = 0.0004) compared with placebo. Reduction of polyp size was greater in patients with sinus surgery (RR, 0.31; 95% confidence interval [CI], 0.20, 0.48) than those without (RR, 0.61; 95% CI, 0.46, 0.81; p = 0.009). Greater symptom improvement occurred when sinus delivery methods (SMD, -1.32; 95% CI, -2.26, -0.38) were compared with nasal delivery methods (SMD, -0.38; 95% CI, -0.55, -0.22; p < 0.00001).

CONCLUSION

INCS is effective for CRS. Prior sinus surgery and direct sinus delivery enhance the effectiveness of INCS in CRS.

Lysosomal exoglycosidases in nasal polyps

INTRODUCTION

Nasal polyps are smooth outgrowths assuming a shape of grapes, formed from the nasal mucosa, limiting air flow by projecting into a lumen of a nasal cavity. Up to now the surgical resection is the best method of their treatment, but etiology and pathogenesis of the nasal polyps is not yet fully established.

AIM OF THE STUDY

The aim of the study was the assessment of the selected lysosomal exoglycosidases activity in the nasal polyps. In this study the activity of β-galactosidase, α-mannosidase and α-fucosidase was determined in the tissue of the nasal polyps obtained from 40 patients (10F, 30M) and control tissues derived from mucosa of lower nasal conchas obtained during mucotomy from 20 patients (10F, 10M).

RESULTS

We observed significant lower values of GAL, FUC and tendency to decrease of MAN and GLU concentration in nasal polyps (P) in comparison to control healthy nasal mucosa (C). In nasal polyp tissue (P) no differences of GAL, MAN and FUC specific activity in comparison to control mucosa (C) were found.

CONCLUSIONS

Our research supports bioelectrical theory of the nasal polyps pathogenesis and directs attention at research on glycoconjugates and glycosidases of the nasal mucosa extracellular matrix.

Effects of Budesonide on the Expression of the Glucocorticoid Receptor-α in Nasal Polyp Epithelial Cells

Background

This study explores effects of budesonide on the proliferation of nasal polyp epithelial cells and expression of the glucocorticoid receptor (GR) alpha in nasal polyp epithelial cells.

Methods

Primary cultured, purified, and identified the epithelial cells collected from nasal polyps. The proliferation of nasal polyp epithelial cells was examined by a cell counting kit, and expression of GR-alpha mRNA in nasal polyp epithelial cells was examined by reverse transcription polymerase chain reaction, after training nasal polyp epithelial cells in budesonide solution.

Results

The average survival rate of nasal polyp epithelial cells was the lowest in 1 × 10−6 M budesonide solution (29.284 ± 0.311%), compared with other concentrations. Budesonide at 1 × 10−8 M caused down-regulation of GR-alpha mRNA expression levels at 6 and 12 ours, compared with the 0-hour group (p < 0.001); compared with the 0-hour group, there were significantly lower expression levels of GR-alpha mRNA at both 24 and 48 hours (p < 0.001); Expression of GR-alpha mRNA at either 48 or 12 hours was not significantly different from that at 24 hours.

Conclusion

Budesonide can significantly inhibit the proliferation of nasal polyp epithelial cells, down-regulate the expression of GR-alpha mRNA in nasal polyp epithelial cells with time dependence.

A novel sinonasal endoscopy scoring system: the discharge, inflammation, and polyps/edema (DIP) score

BACKGROUND

There is an increasing need for a validated grading system to assess sinusitis severity as observed on endoscopic examination. Existing endoscopy scales have limitations in complexity, validation, and/or applicability. We present a novel and straightforward endoscopic scoring system measuring discharge, inflammation, and polyps/edema (DIP). The aim of this study is to determine correlation of the DIP score with existing sinus endoscopy scoring systems, and to determine interrater and test-retest reliability.

METHODS

This retrospective cohort includes a total of 29 patients who underwent functional endoscopic sinus surgery (FESS) for chronic rhinosinusitis. Sinus endoscopy videos were scored in a random and blinded fashion by 3 rhinologists (S.D.P., A.N.G., A.H.M.) using the Lund-Kennedy Endoscopic Score (LKES), the Perioperative Sinus Endoscopy (POSE) score, and the DIP score. Pearson correlation coefficients, interrater reliability and test-retest reliability were determined.

RESULTS

The results of this study show that the DIP score correlates well (p < 0.0001) with the existing LKES and POSE (Pearson correlation coefficients of 0.78 and 0.90, respectively). The interrater reliability intraclass correlation coefficient (ICC) is highest for the DIP score (0.87), followed by the POSE score (0.84) and the LKES (0.78). Test-retest reliability ICC is highest for the DIP score (0.78), followed by the POSE score (0.59) and the LKES (0.53).

CONCLUSION

The DIP score is a novel and straightforward endoscopic sinus scoring system that shows substantial test-retest and interrater reliability in the post-FESS population. It also demonstrates a high correlation with existing scoring parameters (LKES and POSE).

State of the art treatment of nasal polyposis

BACKGROUND

Nasal polyposis represents the end point of multiple inflammatory pathways and controversy continues as to the exact roles of medical and surgical approaches in the management of nasal polyposis.

METHODS

A combination of both is often required to manage polyps adequately with surgery and intranasal steroids remaining the mainstay of therapy.

RESULTS

Fortunately, new technological advances are making surgery safer and more efficient. In the postoperative period, debridement is effective in reducing the formation of adhesions, and topical medications may play a beneficial role in preventing polyp reformation.

CONCLUSION

Additional investigations into the optimal perioperative medical management is needed to ensure optimal surgical outcomes.

Effect of a dexamethasone Sinu-Foam™ middle meatal spacer on endoscopic sinus surgery outcomes: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Off-label drug eluting middle-meatal spacers have shown promising results for improving clinical outcomes following endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). This study evaluates a dexamethasone Sinu-Foam™ spacer following ESS for CRS without nasal polyposis (CRSsNP).

METHODS

Patients with CRSsNP (n = 36) were enrolled into a double-blind, placebo-controlled trial and randomized into either a treatment arm (dexamethasone Sinu-Foam™ mixture; n = 18) or placebo arm (Sinu-Foam™ alone; n = 18). Therapeutic outcomes were evaluated at 1 week, 4 weeks, and 3 months using sinonasal endoscopy and graded using the Lund-Kennedy scoring system. Postoperative care included nasal saline irrigations and a short course of systemic steroids.

RESULTS

All patients completed the study follow-up period. Both study arms experienced significant improvement in endoscopic grading over the study duration (p < 0.001). There was no difference in average endoscopic scores between the treatment and placebo groups at 1 week, 4 weeks, and 3 months (all p > 0.489).

CONCLUSION

This study demonstrated that an off-label drug-eluting middle-meatal spacer of dexamethasone and Sinu-Foam™ does not improve endoscopic outcomes in the early postoperative period following ESS when combined with postoperative saline irrigations and a short course of systemic steroids.

Nasal polyposis: current trends

Nasal polyps (NP) are one of the most common inflammatory mass lesions of the nose, affecting up to 4% of the population. They present with nasal obstruction, anosmia, rhinorrhoea, post nasal drip, and less commonly facial pain. Their etiology remains unclear, but they are known to have associations with allergy, asthma, infection, fungus, cystic fibrosis, and aspirin sensitivity. However, the underlying mechanisms interlinking these pathologic conditions to NP formation remain unclear. Also strong genetic factors are implicated in the pathogenesis of NP, but genetic and molecular alterations required for its development and progression are still unclear. Management of NP involves a combination of medical therapy and surgery. There is good evidence for the use of corticosteroids (systemic and topical) both as primary treatment and as postoperative prophylaxis against recurrence, but the prolonged course of the disease and adverse effects of systemic steroids limits their use. Hence several new drugs are under trial. Surgical treatment has been refined significantly over the past 20 years with the advent of endoscopic sinus surgery and, in general, is reserved for cases refractory to medical treatment. Recurrence of the polyposis is common with severe disease recurring in up to 10% of patients. Over the last two decades, increasing insights in the pathophysiology of nasal polyposis opens perspective for new pharmacological treatment options, with eosinophilic inflammation, IgE, fungi and Staphylococcus aureus as potential targets. A better understanding of the pathophysiology underlying the persistent inflammatory state in NP is necessary to ultimately develop novel pharmacotherapeutic approaches. In this paper we present the newer treatment options available for better control and possibly cure of the disease.